The Journal of Laryngology & Otology

November 2001, Vol. 115, pp. 874878

Main Articles
Adult-onset otitis media with effusion: results following
ventilation tube insertion
M. W. Yung, Ph.D., F.R.C.S., D.L.O., R. Arasaratnam, F.R.C.S., D.L.O.

Abstract
The outcome of otitis media with effusion (OME) in children is generally good. However, it is less clear in
adults. All adult patients who had a ventilation tube inserted for OME at the Ipswich Hospital between
1996 and 1997 were studied. Of 53 patients studied, 28 had had a previous history of ventilation tube
insertion. Furthermore, at 1527 months following ventilation tube insertion, the ventilation tube had
already extruded in 31 patients and the OME had already recurred in 19 of these. Endoscopic
examination revealed that many patients still had evidence of inammation at the lateral nasal wall (26.4
per cent) and at the eustachian tube orice (51 per cent). There is also a strong history of atopy in the
studied group and the skin prick test was positive in 57 per cent of the patients. This study shows that
many patients with adult-onset OME have underlying pathology that could lead to recurrence of OME
following ventilation tube extrusion.
Key words: Otitis Media with Effusion; Middle Ear Ventilation

Introduction
Otitis media with effusion (OME) is one of the
commonest causes of paediatric referral to an otolaryngologist. While it is accepted that most OME in
children resolves with time, a signicant number of
cases still result in ventilation tube insertion. It has
been reported that 70 per cent of children had
complete resolution of OME following one ventilation
tube insertion and a further 20 per cent resolution
1
following a second ventilation tube insertion. On the
whole, most clinicians agree that most children with
OME have a good outcome, mainly as a result of the
natural resolution of the disease.2
The outcome of adult-onset OME is less wellestablished. It is known that OME secondary to
nasopharyngeal carcinoma will not respond well to
ventilation tube insertion and will very often result in
persistent discharge through the tube.3
The aim of the present study is to examine the
outcome of ventilation tube insertion in patients with
non-tumour related adult-onset OME. Any underlying nasal, nasopharyngeal and atopic factors will
also be examined.

Committee. Written consent from the patient was

exempted by the Ethics Committee. All adult
patients with OME who had ventilation tube
insertion at the Ipswich Hospital NHS Trust between
June 1996 and June 1997 were studied. Those with
known head and neck tumours were excluded. For
the purpose of the present study, all patients were
recalled to the out-patient clinic 15 to 27 months
following ventilation tube insertion for assessment.
Information regarding previous history of ventilation
tube insertion, the onset of the OME (adult-onset or
a continuation of childhood problems) as well as any
history of atopy was obtained. A systematic enquiry
was made concerning symptoms of rhino-sinusitis
including sneezing ts, nasal blockage, rhinorrhoea
and facial pain. A symptom was regarded as chronic
if it had been present for longer than three months.
The indication for, the side of ventilation tube
insertion, the operative ndings and the nature of
the middle-ear uid were obtained by reviewing the
patients case record.
A full ENT examination including otoscopy, rigid
nasal endoscopy using the Hopkins rod and breoptic examination of the nasopharynx was also
performed on all patients. The status of the ventilation tube, the appearance of the eardrum and any
recurrence of the OME were documented. Recur-

Patients and methods

The protocol of the study was reviewed and
approved by the East Suffolk Local Research Ethics

From the Department of Otolaryngology, The Ipswich Hospital NHS Trust, Ipswich, UK.
Accepted for publication: 14 June 2001.
874

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adult-onset otitis media with effusion: results following ventilation tube insertion
TABLE I
surgical outcome of 53 adult patients suffering from
chronic otitis media with effusion (ome) 15 to 27 months
following ventilation tube (vt) insertion
Outcome

Number of
patients (n = 53)

VT still in situ
VT already extruded
Recurrence of OME following VT extrusion
Persistent/recurrent discharge from VT

22
31
19
4

rence of the OME was further conrmed by

tympanometry. In an attempt to blind the endoscopist to the status of the OME and the ventilation
tube, rigid nasal endoscopy and bre-optic examination of the nasopharynx were carried out by the
senior author (MWY) prior to the review of the
patients record and examination of the ears.
The nasal endoscopic ndings were categorized
into normal, gross septal deviation, presence of
mucopus at the lateral nasal wall and polypoidal
mucosa at the lateral nasal wall. Severe septal
deviation was reported only if it resulted in complete
blockage of the corresponding nostril.
The ndings of bre-optic examination of the
nasopharynx were categorized into normal, presence of mucopus at the eustachian tube orice and
oedema/hyperaemia of the tori tubarii. Any growth
including enlarged adenoids in the nasopharynx was
noted.
All patients then had a skin-prick allergy test
performed by the junior author (RA) who was
blinded to the otoscopic and endoscopic ndings of
the patients. Up to 28 different allergens were used
in the skin-prick test including inhalant and food
allergens. In addition, all patients had a blood test
for serum IgE level.
Results
A total of 53 patients had ventilation tube insertion
performed between June 1996 and June 1997. They
were between 27 and 88 years old. Twenty-one were
male and 32 were female. Only four patients had
OME which had started during childhood; the rest
had adult-onset OME. The OME was bilateral in 31
patients and unilateral in 22 patients. As a result, 31
patients had bilateral ventilation tube insertion and
22 patients had ventilation tube insertion only in the
affected ear. Eleven out of 53 patients had T-tubes

inserted whereas the rest (42 patients) had either

Shepherd or Shah grommets inserted.
Of the 53 patients studied, 28 already had a
previous history of ventilation tube insertion and the
most recent ventilation tube was inserted for
recurrence of the OME. Fourteen patients had had
one set, four had had two sets and 10 had had three
or more sets of ventilation tube inserted previously.
There was no dry tap on any of the myringotomies.
Forty-one of the 53 patients had thin uid and 12 had
thick glue aspirated from the middle ear on
myringotomy.
At the time of the follow-up assessment 15 to 27
months following ventilation tube insertion, 22 out of
53 patients still had at least one ventilation tube in
situ. Eleven patients had in-dwelling T-tubes and 11
patients had in-dwelling grommets. For the other 31
patients, the ventilation tubes were already extruded
from the ears. Table I summarizes the outcome of
the patients. Nineteen patients (61 per cent) had
recurrence of OME following extrusion of the
ventilation tube. For those with the ventilation tube
still in situ, four (18 per cent) had either a recurrent
or persistent discharge from the ventilation tube.
Table II illustrates the endoscopic ndings of the
nose on all the patients who had ventilation tube
insertion and also the sub-group whose ventilation
tube had already extruded. Inammation at the
lateral nasal wall was dened as the presence of
either mucopus or polypoidal mucosa at the lateral
nasal wall. Many patients in the present study (26.4
per cent) had endoscopic evidence of pathology in
the nasal cavity, including signs of inammation at
the lateral nasal wall (20.8 per cent). However, there
is no statistical difference in the nasal endoscopic
ndings between the groups of patients with, and
without, recurrence of OME following extrusion of
the ventilation tube (using Yates-corrected Chisquared, p>0.5). With the presence of mucopus at
the eustachian tube orice or oedema/hyperaemia of
the tori tubarii being taken as evidence of inammation, 51 per cent of the patients had inammation at
the eustachian tube orice at the time of assessment
(Table III). Again, there is no statistical difference in
the appearance at the eustachian tube orice
between the groups of patients with, and without,
recurrence of OME following extrusion of the
ventilation tube (using Pearson Chi-squared statistic,
p>0.05).

TABLE II
nasal endoscopic ndings of 53 adult patients suffering from chronic otitis media with effusion (ome) at 15 to 27 months
following ventilation tube (vt) insertion
Patients with VT extruded (n = 31)

Nasal endoscopic ndings

Normal
Severe septal deviation
Inammation at lateral nasal wall

All patients with

VT insertion
(n = 53)

Recurrence of
OME
(n = 19)

No recurrence
of OME
(n = 12)

Patients with
VT still in situ
(n = 22)

39
5
11

12*
1*
7*

9*
2*
1*

18
2
3

Note: *Comparing normal and abnormal endoscopic nding between the OME recurrence group and No recurrence group using
Yates-corrected Chi-squared test, p>0.5.

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m. w. yung, r. arasaratnam

TABLE III
appearance of eustachian tube ori ce of 53 adult patients suffering from chronic otitis media with effusion (ome) at 15 to
27 months following ventilation tube (vt) insertion
Patients with VT extruded (n = 31)

Appearance of eustachian tube orice

Normal
Mucopus at ET orice
Oedema/Hyperaemia at ET orice

All patients with

VT insertion
(n = 53)

Recurrence of
OME
(n = 19)

No recurrence
of OME
(n = 12)

Patients with VT
still in situ
(n = 22)

26
12
20

8*
8*
7*

8*
0*
4*

10
4
9

Note: *Comparing the normal and abnormal appearance at the ET orice between the OME recurrence group and No recurrence
group using Pearson Chi-squared statistic, p>0.05.

Nineteen out of 53 patients (35.8 per cent) in the

present study also suffered from chronic symptoms
of nasal blockage, rhinorrhea or sinus pain. Table IV
illustrates the correlation between the nasal endoscopic ndings and the clinical symptoms of chronic
rhino-sinusitis. Among patients with normal nasal
endoscopic ndings (n.=.38), only about 20 per cent
displayed concomitant symptoms of rhino-sinusitis.
However, amongst patients having either severe
septal deviation or inammation at the lateral nasal
wall (n.=.16), nearly 70 per cent displayed concomitant nasal symptoms. This greater incidence is highly
signicant (Yates-corrected Chi-squared, p< 0.01).
Of the 53 patients in the present study, 23 (43 per
cent) had a known history of atopy. Nine were
asthmatic; nine had hay fever and six were eczema
sufferers. Table V illustrates the number of patients
with positive skin prick allergy tests and raised serum
IgE level, again comparing the total patient group
and the sub-group with ventilation tube already
extruded. There is no statistical difference in the
results of skin-prick testing or the serum IgE level
between the groups of patients with, and without,
recurrence of OME following extrusion of the
ventilation tube (Yates-corrected Chi-squared,
p>0.5). The commonest allergens identied by
skin-prick testing in the present study were housedust mite (19 patients), grass or tree (11 patients),
wheat (ve patients), cat or dog (four patients),
Alternaria (four patients) and Aspergillus (two
patients). However, only seven out of 53 patients
had an increase in the serum IgE level.
Discussion
The Ipswich Hospital NHS Trust serves a population
of 350.000. Between 1996 and 1997, 53 adult patients
had ventilation tube insertion for OME at the

Department of Otolaryngology, which suggests that

adult-onset OME is not uncommon. The main task
for a clinician is to identify the underlying cause of
the OME as well as alleviating the symptoms for the
patient. Hence, endoscopic examination of the nose
and nasopharynx is regarded as an essential part of
the management, especially as our study reveals that
35.8 per cent of patients also had concomitant
symptoms of chronic rhinosinusitis. Biopsy of the
nasopharynx or computed tomography (CT) scanning is often necessary in unilateral OME to exclude
a nasopharyngeal tumour. The examination of the
nasopharynx was performed 1527 months following
ventilation tube insertion and biopsy of the nasopharynx. It was assumed that after such a long
interval, any abnormality noted at the eustachian
tube area was unlikely to be the residuum of the
previous biopsy scarring. The present study concentrates on non-tumour related OME in adults. Over
20 per cent of patients in this study had endoscopic
evidence of inammation at the lateral nasal wall.
This nding is in agreement with other reports that
there is a strong connection between OME and
chronic sinusitis. Finkelstein et al. reported that
OME was the presenting symptom in 23 per cent of
patients suffering from chronic sinusitis.4 In another
prospective study on 167 consecutive patients with
adult-onset OME, they reported that 19.8 per cent of
the patients had a history of persistent nasal
symptoms of more than three months duration
prior to the onset of the OME. Nasal endoscopy of
that particular group of patients revealed purulent
discharge coming from the lateral nasal wall in over
70 per cent of the subjects and ethmoidal polypoidal
disease in 45 per cent of the subjects. 5
It is commonly agreed that many cases of otitis
media originate from ascending infection through
the eustachian tube. Using restriction fragment

TABLE IV
symptoms of chronic rhino-sinusitis in correlation to the nasal endoscopic ndings in 53 adult patients with chronic otitis
media with effusion (ome)

Nasal endoscopic ndings

Normal
Severe septal deviation
Inammation at lateral nasal wall

Number of patients with concomitant

symptoms of rhino-sinusitis (blocked Number of patients with no
Number of patients
nose, rhinorrhoea or sinus pain)
symptoms of rhino-sinusitis
38
5
11

8
2
9

30
3
2

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adult-onset otitis media with effusion: results following ventilation tube insertion

TABLE V
skin prick test results and serum ige level of 53 adult patients suffering from chronic otitis media with effusion (ome) at 15
to 27 months following ventilation tube (vt) insertion
Patients with VT extruded (n = 31)

Positive skin prick test

Negative skin prick test
Raised serum IgE level
Normal serum IgE level

All patients with VT

insertion (n = 53)

Recurrence of
OME (n = 19)

No recurrence of
OME (n = 12)

Patients with VT
still in situ (n = 22)

30
23
7
46

10*
9*
4**
15**

5*
7*
2**
10**

15
7
1
21

Note: *Yates-corrected Chi-squared, p>0.5.

**Yates-corrected Chi-squared, p>0.5.

mapping of non-typable Haemophilus inuenzae

recovered from paired nasopharyngeal and middleear uid cultures in children with OME, Bernstein
et.al. reported that the strains of bacteria in the
nasopharynx and the middle ear of a particular
subject were indistinguishable, but that they were
different between different subjects.6 They concluded that OME caused by Haemophilus
inuenzae involves spread of the bacteria from the
nasopharynx to the middle ear. Takahashi et al.
studied 78 adult ears with OME and observed
oedema of the eustachian tube orice in 26.9 per
cent of the ears and mucopurulent discharge blocking the tube in 23.1 per cent of the ears.7 In our
study, 51 per cent of patients still had evidence of
inammation at the eustachian tube orice 15 to 27
months following ventilation tube insertion. It is,
therefore, not surprising that 19 out of 31 patients
(61 per cent) had recurrence of OME following
extrusion of the ventilation tube and four out of the
remaining 22 patients (18 per cent) had troublesome
discharge from the ventilation tube. However, we
could not demonstrate any difference in the endoscopic ndings at the lateral nasal wall or at the
eustachian tube orice between the groups of
patients with, and without, OME recurrence. The
observation that over 50 per cent of all patients in
this study had previous ventilation tube insertion was
further evidence that the long-term benet of
ventilation tube alone in adult-onset OME is limited.
It is interesting that Finkelstein reported that in 31
out of 33 adult patients who had OME associated
with chronic sinusitis, the middle-ear effusion and
negative middle-ear pressure were normalized after
successful conservative or surgical treatment of the
sinusitis. Marked regression of the hypertrophied
adenoids and disappearance of the oedema and
hyperaemia of the eustachian tube orice were
observed in all patients exhibiting resolution of
sinusitis and OME.4 El-Guindy also reported that
normalization of tubal function was achieved in 17
out of 32 patients after correction of the nasal and
peri-tubal abnormality.8
The present study also demonstrates a strong
association between adult-onset OME and atopy.
Twenty-three out of 53 patients (43 per cent) had a
known history of atopy. More importantly, 30 out of
53 patients (57 per cent) had a positive skin-prick
test. This is higher than among the general population, which has a reported positive skin-prick test of

up to 30 per cent.9 This further supports the

connection between atopy and OME in adults.
Based on critical analysis of history together with
allergy tests, Bernstein estimated that OME in
children is also associated with allergy in 35 to 40
per cent of cases. 10 In a double-blind study,
Friedman et al. showed that provocative nasal
challenge to an allergic individual produced eustachian tube obstruction, preceded by allergic
rhinitis.11 More dramatic ndings on the correlation
between OME and allergy were reported by
McMahan et al. They studied children with OME
and found that 93 per cent of 111 children had a
positive radio-allergosorbent test (RAST). They
further reported a success rate of 91 per cent in
treating refractory chronic otitis media with allergy
therapy for inhalants and food.12 The role of IgEmediated hypersensitivity in the development of
OME is still unclear. It has been suggested by
Bernstein et al. that in patients with OME, the
middle-ear mucosa itself is rarely a target organ of
allergy. They studied 100 children with recurrent
OME and found that the IgE level in the middle-ear
effusion was higher than that in the serum in only
eight per cent.13 It was postulated by Bernstein et al.
that the release of biological mediators of inammation from basophils and mast cells at the nasal and
nasopharyngeal mucosa produces eustachian tube
oedema and inammation. However, Hurst and
Fredens studied the eosinophil cationic protein in
the middle-ear mucosa in patients with both allergy
and OME concluded that there is an intrinsic
immune-mediated process involving eosinophils
14
activated within the middle ear itself. Recognizing
the importance of allergy in OME, Hurst investigated the use of immunotherapy and a food
elimination diet in 20 patients with refractory
OME. All 20 patients were found to have allergic
sensitivity and for the 11 patients who complied with
the allergy management, all had resolution of the
OME and remained free of recurrence for more than
three years. The other nine patients who either
refused or could not comply with the allergy
treatment had persistence of the OME.15 In the
present study, none of our adult patients received
either immunotherapy or a food elimination diet
although those patients with hay fever and asthma
had received a steroidal nasal spray or an inhaler
prescribed by their general practitioner.

878

In contrast to the strong evidence in the literature

concerning the relationship between OME, chronic
rhino-sinusitis and allergy, we could not demonstrate
a correlation between OME recurrence and the
atopic status of the patients or the endoscopic
ndings in the nose and nasopharynx. However, we
recognized that the number of subjects in the present
study was relatively small. A prospective study
involving a bigger number of patients may provide
a more denitive answer in the future.
In conclusion, adult-onset OME is frequently
associated with chronic rhino-sinusitis (21 per cent)
or atopy (57 per cent). The resulting inammation at
the eustachian tube orice often persists following
insertion of the ventilation tube (51 per cent).
Hence, treatment with ventilation tube alone frequently leads to failure, with either recurrence of the
OME following ventilation tube extrusion (61 per
cent) or troublesome discharge from the ventilation
tube (18 per cent). Therefore, it seems logical to
treat underlying pathology such as chronic sinusitis
or atopy as there are encouraging reports in the
literature of a more favourable outcome of OME
following such treatment.
Acknowledgement
The authors would like to thank Dr Graham Upton
of the Department of Mathematics, University of
Essex for statistical advice.
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Address for correspondence:
Mr M. W. Yung,
Department of Ear, Nose and Throat,
The Ipswich Hospital NHS Trust,
Heath Road, Ipswich,
Suffolk IP5 4PD, UK.
Fax: 01473 287 135
E-mail: yung@doctors.org.uk
Mr M. Yung takes responsibility for the integrity of the
content of the paper.
Competing interests: None declared